Provider Demographics
NPI:1689450066
Name:BENEVENTE, KELLY JEAN (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:BENEVENTE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:BENEVENTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NONE
Mailing Address - Street 1:39 WINDCREST DR
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2922
Mailing Address - Country:US
Mailing Address - Phone:631-235-3175
Mailing Address - Fax:
Practice Address - Street 1:100 S MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-3148
Practice Address - Country:US
Practice Address - Phone:631-602-0079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119007104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker